If you are completing this form on behalf of the Service Recipient, you MUST be the Service Recipient's legal Power of Attorney, and you must provide the Power of Attorney documentation.
Check all that apply
Assessment of Needs
Source of Financial Support/Financial Arrangements
Please provide the following documents if available
Rights and Confidentiality:
You have the right to voice grievances to the staff of the agency, to the owner of the agency, and to outside representatives of your choice with freedom from intereference, coercion, discrimination, or reprisal.
Any questions or specific concerns regarding service recipient's rights or to report a complaint may be directed to the following:
I have been explained and received a copy of Service Recipient Rights, Confidentiality, Responsibilities, and Grievance Procedures.
It is the policy of the Personal Support Services agency that a criminal history background check be done for all people who provide direct care or have direct contact with elderly or disabled people in their home. Prestige Homecare will make sure a background check has been completed on each employee before he/she comes to your house to help you.
Our agency is required to provide training annually to our employees so you can be assured that they can perform their duties. Our employees have promised to foster respect, dignity, privacy, and confidentiality for the people that we serve. This includes allowing people to decide whether to be a part of a program or activity.
Our employees must cooperate with any other service providers and provide services in an efficient, cost effective manner. Also, our employees must not improperly attempt to gain any money or goods from any participant or their family.
If you have any questions or problems with anyone coming to your home to provide home and community based services, please call Prestige Homecare, LLC at (256) 619-0144
I have read and understand Prestige Homecare's Policy & Procedures. I agree to follow Prestige's guidelines to the best of my ability.
I authorize Prestige Homecare, LLC to provide medication assistance as designated by the agreed Service Plan. Medication assistance includes, but is not limited to, any of the following:
I understand that I must notify the agency of any changes in the medication
CONFIDENTIALITY AND NON-SOLICITATION AGREEMENT FOR SERVICE RECIPIENTS
In consideration of my professional affiliation with Prestige Homecare, LLC (“Prestige”) and/or its affiliates or successors, I agree as follows:
I acknowledge that Confidential Information may be made available to me and/or developed by me during my affiliation with Prestige.Confidential Information consists of all information belonging to Prestige that has been identified as confidential. Confidential Information includes, but is not limited to, hourly fee rates, proprietary information of Prestige,etc., and information related to Presitge’s employees and/or caregivers.I acknowledge that as a result of my affiliation, a duty has been imposed on me to not use Prestige’s Confidential Information on my or another party’s behalf and/or personal, financial, or professional gain.
Non-Solicitation of Caregivers
For a period of twelve months after the date of termination of my services from Prestige for any reason, I agree that I will not, directly or indirectly, hire, attempt to hire, solicit for employment or encourage the departure of any employee of Prestige, to leave employment with Prestige.
Agency: Prestige Homecare, LLC
The rate for providing services is $ * per hour. The rate for overnight services is $ * per hour at night.
The services will be provided at a minimum of 40 hours per week (unless otherwise decided) , and will not exceed 168 hours per week.
Services will terminate if an invoice is not paid by the date it is due.
A Service Recipient may cancel services at any time with a written 30 day notice of the intended cancellation date.
I understand and accept the terms of this agreement for the services to be provided as determined in the "Service Care Plan"